HomeMy WebLinkAbout- Septic Pumping Slip - 365 BOSTON STREET 6/4/2019 i
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System Pumping Record
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DEP has provided Form 4
informadon-must be su,bstinflally'the tame as that provided here. Before using.this foffn,,check with your
locil Board of Healthq r e.The rdgut be submitted to
Boardthe local r r .
RightA. Facility InforMatison
1. System Location: Left I ht front of house Left I Right rear of.house, Leftl rlg ht side of house Left I
r l . , Under
f
Address
-:3
ion
City/Town i Code.
x
Systern Owner,
Address Of different from to
C1WMn
Telephoneumber
B. Pumping Recor d
OtherDate of Pumping Date 2. Qu6nfity Pumped: Gallons ------------
3. Type-of system: E) Cesspool(s), 0--s-epric,Tank (j, Tight Tank
(describe):
Filter4. Effluent Tee nth If yes, was it cleaned?
5. i
"Iet
6.
System
By.-
Nell.
Name hide l umber
Bateson
Company
were disposed.
Lowell W,aste Water 4tHhul , Date
Wbrm4.doca 06/03 System Pumpi r